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2 Purpose of Presentation To provide guidelines for the effective identification, assessment, and treatment of Pathological Gambling, whether given as an initial problem or identified as secondary to another presenting problem. To increase the effectiveness of treatment for pathological gamblers means that we need to treat the client for the entire range of problems they experience. To do it in a planned logical sequence, and at a rate that is tolerable for the client.

3 The following protocol describes the process by which Heartland Family Service has organized our system to effectively identify and treat pathological gamblers as dually diagnosed or multi-problem clients, and how we minimize barriers to effective treatment.

4 Essential Principle of Integrated Treatment Dual (or more) diagnosis is the usual, and not the exception. It is common enough that it is important to screen and assess for co-morbid conditions when assessing for a pathological gambling diagnosis. If a mental health problem or a substance abuse disorder co-exist with a pathological gambling disorder, both diagnoses should be considered primary, and both should be treated simultaneously rather than serially.

5 Essential Principles of Integrated Treatment A psychiatric or substance abuse disorder should be considered secondary only if it resolves when the pathological gambling disorder is at baseline.

6 Key Factors in Integrated Treatment Primary Therapist: The best predictor of progress for clients is a strong, effective, and enduring therapeutic relationship. When a client does receive treatment from more than one provider in the agency, one person is designated as the primary therapist. This will probably be the therapist who is most likely to have a long and/or in-depth involvement in the treatment process. This person will initiate case management or coordination efforts, and continue to monitor progress in all areas of treatment.

7 Case Management: As treatment becomes more complex it becomes increasingly critical that someone help the client make sense of the overall process. Case management addresses questions of when and to whom to refer, client readiness to accept the referral, planning the sequence of treatment, coordinating the process of treatment with multiple providers, and following up as needed. With pathological gamblers the therapeutic relationship often dictates who takes an active role regarding the coordination and management of treatment.

8 Client Engagement and Readiness to Change: Chances of change are improved that a client will accept our recommendations for a referral to a specialized service when they feel that their presenting problem has been heard and understood. The therapeutic relationship and the joining process help build client motivation and readiness to change. Some clients may stay in the pre-contemplation stage for a period of time during which various clinical interventions may help them get ready to change.

9 Staff Considerations: Integrated treatment requires the development of a clinical staff with skills that cross the traditional professional boundaries and move in new directions, including the following: 1. Recruiting, hiring, and developing existing employees to obtain dual credentials 2. Cross training of staff to recognize, refer, and cooperatively treat clients with a range of problems 3. Co-location of staff with specialized credentials throughout service locations

10 Client Eligibility: 1. The client demonstrates symptoms of an Axis 1, pathological gambling diagnosis. 2. If there is a diagnosis of substance abuse/or mental health diagnosis such as Depression, it is amenable to outpatient treatment. 3. Treatment can realistically be expected to help the client improve and maintain their level of functioning. 4. If there is a suicidal ideation or other risks to safety; it is possible to develop an effective safety plan which the client and/others in their environment will follow. 5. If there is a major mental disorder that affects or limits the effectiveness of the treatment process, the client is willing to be seen by a PhD or MD for diagnosis and concurrent treatment of the disorder, and be compliant in treatment recommendations, including medication if needed. 6. There is reasonable motivation and cooperation from the client and significant others involved in treatment.

11 Clients Are Inappropriate For Treatment When: 1. Client is unable to or unwilling to commit to and adhere to a safety plan to protect from self harm or harm to others. 2. Client is unwilling to obtain medical or psychiatric treatment, or to follow these treatment recommendations 3. Client is assessed as needing a high level of care 4. Client is medically at risk such as addiction or eating disorder at a level of severity that health is affected. 5. There is a high risk of domestic violence or child abuse, and the client(s) must be provided with a safe environment before engaging in the treatment process.

16 Treatment frequency, Intensity Individualized Highly Flexible Intensity one to five times a week with a combination of group, family, individual therapy, and psychiatric consultation available.

17 Treatment Duration Pathological gamblers with dual diagnosis tend to benefit from long term supportive contacts with treatment professionals. Duration may be a minimum of six months, and for some individuals the maintenance phase needs to open ended and long term.

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